Join Kyndred: Provider Interest Form
Thank you for your interest in Kyndred! We're excited to connect with providers who are passionate about offering affirming, inclusive care for Black women. Please note, this is an interest form and not a job application.  By filling out the form below, we can learn more about your expertise, interests, and how you may align with Kyndred’s mission and values. If there is alignment, we will reach out to you as we prepare for our launch in 2025.
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First Name *
First Name
Last Name *
Last Name
Email *
State of Residence *
How do you identify racially or ethnically? (Select all that apply) *
Required
If you selected "Other", please specify.
How do you describe your gender? (Select all that apply) *
Required
If you selected "Other", please specify.
How do you describe your sexual orientation? (Select all that apply) *
Required
If you selected "Other", please specify.

What is your professional degree or credential? (Select all that apply)

*
Required
What areas of care do you specialize in? (Select all that apply) *
Required
If you selected "Other", please tell us what other areas of care you specialize in. 
What are your primary clinical interests or areas you’re passionate about? *
Do you have training or experience in reproductive justice frameworks, culturally affirming care, and gender-affirming practices? *

Please list all states where you currently hold an active license. (Select all that apply)

*
Required
What languages are you able to conduct clinical care? (Select all that apply)
If you selected "Other", please specify. 

Are you credentialed with any of the following insurers? (Select all that apply)

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Required
If you selected "Other", please tell us what other insurers you are credentialed with. 
Do you currently have an established patient panel? This refers to the patients you regularly see or manage in your practice or clinic.
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If you selected "Other", please specify. 
Please share your LinkedIn profile (optional):
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